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` + R SAN JOAQUIN COUNTY <br /> - ENVIRONMENTAL HEALTH DEPARTMENT <br /> '�., .y 600 East Main Street, Stockton, CA 95202-3029 <br /> I Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> 7 j� 5 Page of <br /> Facility Address: City: Inspects I <br /> n DAte. <br /> FA#: PR#: Program Ele ent: <br /> 2 -0 <br /> TanklContainer Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> 0 Tank (2820) ElContainers (2821) #o#Containers: TA#: <br /> 1 Product Type: <br /> Total Capacity: d 0-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type:, <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #o#Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> All <br /> EHD Inspector: �r Reviewed Date: Entered hate: <br /> By Initial: By Initial: <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />